Category I, CE b) Claimant/Appointment Letter Information (subset of "CE Forms Samples" category)

See Revised Privacy Act and
PRA Statements attached.

PRIVACY ACT STATEMENT
Collection and Use of Information by the Social Security Administration

The Privacy Act of 1974 (5 U.S.C. § 552a) requires us to provide certain facts to each person from whom we
request and collect information in order to administer our programs. These facts include:
• the statutory authority for the request;
• why we need the information;
• whether it is voluntary or mandatory for you to give us the information and the effects, if any, of not
giving us the information; and
• the uses we may make of the information you give us.
The following sections explain our collection, use, and disclosure of the information you give us. If you have
any questions about your rights and responsibilities under the Privacy Act, you may contact any local Social
Security office.
Our authority to collect information
Our specific authority to collect information is found
in sections 205(a), 702, 1631(e)(1)(A) and (B),
1631(f), 1872, and 1875 of the Social Security Act
(the Act), as amended. Additional authority is in
part B of the Federal Coal Mine Health and Safety
Act of 1969.

information to another agency or person without
your written consent. We make these disclosures
for the following reasons:
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•
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Why we need the information
We collect information from you in order to
administer our programs. Specifically, the
information we request enables us to:
•
•
•
•
•

assign Social Security numbers;
establish and maintain earnings records;
determine entitlement of applicants and
their families to insurance coverage and or
benefit payments;
issue payments in the right amount for the
right months to people entitled to them; and
conduct program-oriented research in areas
of income distribution and maintenance.

Is providing information voluntary or
mandatory?
It is not mandatory for you to give us the
information we request except in certain instances
explained below. It is usually to your advantage to
comply with our request for information. Failure to
do so, however, could prevent an accurate and
timely decision on a claim you file or result in the
loss of some benefit or service.
Our use(s) of the information you give us
We use the information you give us to administer
our programs. Sometimes we must disclose the

•

to enable a third party or agency to assist us
in establishing your right to benefits or
coverage;
to comply with Federal laws;
to make eligibility determinations in similar
Federal, State, and local health and income
maintenance programs;
to facilitate statistical research, audit, or
investigative activities necessary to assure
the integrity of our programs.

We may also use the information you give us when
we match records by computer. Computer
matching programs compare our records with those
of other Federal, State, or local government
agencies. We use the information from these
matching programs to establish or verify a person’s
eligibility for Federally-funded or administered
benefit programs and for repayment of payments or
delinquent debts under these programs.
A complete list of routine uses of the information
you give us is available in our Privacy Act Systems
of Records Notices. For example, the application
for benefits and supporting documentation of the
factors of entitlement and continuing eligibility is
contained in our Claims Folder System (60-0089);
medical information, doctors’ reports, and State
disability determinations related to a disability claim
is contained in our National Disability Determination
Services File System (60-0044). Additional
information regarding this form, routine uses of
information, and other Social Security programs is
available from our Internet website at
www.socialsecurity.gov or at your local Social
Security office.
Form SSA-5000 (05-2011)

SSA will insert the following revised Privacy Act and PRA Statements into the
form as soon as possible:
Privacy Act Statement
Collection and Use of Personal Information

Sections 205(a), 223(d), 1614(a) and 1631(d) of the Social Security Act, as amended, allow us to
collect this information. Furnishing us this information is voluntary. However, failing to
provide all or part of the information may prevent us from making an accurate and timely
decision on any claim filed.
We will use the information to acknowledge attendance of scheduled medical appointment. We
may also share your information for the following purposes, called routine uses:
1. To private medical and vocational consultants for use in making preparation for, or
evaluating the results of, consultative medical examination or vocational assessments
which they were engaged to perform by SSA or a State agency acting in accord with
sections 221 or 1633 of the Act; and
2. To contractors and other Federal agencies, as necessary, for the purpose of assisting the
Social Security Administration (SSA) in the efficient administration of its programs. We
will disclose information under this routine use only in situations in which SSA may
enter into a contractual or similar agreement with a third party to assist in accomplishing
an agency function relating to this system of records.
In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices
(SORN) 60-0044, entitled National Disability Determination Services File and 60-0089, entitled
Claims Folders Systems. Additional information and a full listing of all our SORNs are available
on our website at www.socialsecurity.gov/foia/bluebook.

Paperwork Reduction Act Statement - This information collection meets the requirements of
44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not
need to answer these questions unless we display a valid Office of Management and Budget
(OMB) control number. We estimate that it will take about 5 minutes to read the instructions,
gather the facts, and answer the questions. Send only comments relating to our time estimate
above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.